Creating records of patients using a browser based hand-held assistant

ABSTRACT

A method, computer program product and system for creating records using a hand-held device capable of recording a voice file. A server may receive a request to select an encounter template, e.g., knee template, from the user of a hand-held computer. The server may transmit one or more screens of the selected encounter template to the hand-held computer. The server may receive a request to generate a voice file from the hand-held computer. A tag file may be generated in response to the request to generate a voice file where the tag file associates the voice file to be generated with the appropriate field the transcription of the voice file is to be inserted in the selected encounter template. Upon transcription of the voice file, the server may insert the transcription in the appropriate field in the template created by the user using the tag file.

CROSS REFERENCE TO RELATED APPLICATION

This application is related to the following commonly owned copendingU.S. patent application:

Provisional Application Ser. No. 60/362,024, “System, Apparatus, andMethod for Point of Service Diagnosis Data Processing”, filed Mar. 5,2002, and claims the benefit of its earlier filing date under 35 U.S.C.119(e).

TECHNICAL FIELD

The present invention relates to the field of healthcare systems, andmore particularly to allowing a healthcare provider to create recordsusing a browser based hand-held assistant capable of recording a voicefile to be later transcribed and inserted in the associated record.

BACKGROUND INFORMATION

Healthcare providers, such as physicians, create large volumes ofpatient information during the course of their business at healthcarefacilities, such as hospitals, clinics, laboratories and medicaloffices. For example, when a patient visits a physician for the firsttime, the physician generally creates a patient file including thepatient's medical history, current treatments, medications, insuranceand other pertinent information. This file generally includes theresults of patient visits, including laboratory test results, thephysician's diagnosis, medications prescribed and treatmentsadministered.

Physicians often use paper based forms and charts to document theirobservations and diagnosis. These paper based forms may be limiting bynot allowing the physician the flexibility of inserting information thephysician deems important Further, these paper based forms containstandard questions that are not necessarily logically relevant to theparticular encounter with the patient Further, these paper based formsare time consuming to fill-out and easy to tear or lose.

Physicians may also dictate their observations and diagnosis using adictation device. However, the transcribed dictation is often insertedin the patient file as a separate document and not part of the paperbased form filled out by the physician. By being a separate paper, thetranscribed dictation is subject to mishandling whereby thetranscription is associated with a wrong patient or encounter.

If physicians were able to create their own forms containing theinformation they deem important for each particular encounter with aparticular patient, the patient file would be more complete bycontaining the physicians complete observations and diagnosis of thepatient for that particular encounter. Further, if physicians couldelectronically create their own forms instead of using paper basedforms, the physicians may spend less time filling out forms. Further, byelectronically creating their own forms instead of using paper basedforms, the forms are less likely to be lost Further, if physicians wereable to create a voice file that is electronically associated with arecord of the encounter and later transcribed and inserted in the formcreated by the physician, then the opportunity for mishandling would bereduced.

Therefore, there is a need in the art for a mechanism to allow ahealthcare provider, e.g., physician, to create records electronicallysuch as using a browser based hand-held assistant capable of recording avoice file to be later transcribed and inserted in the associatedrecord.

SUMMARY

The problems outlined above may at least in part be solved in someembodiments by a server configured to generate a tag file in response toa request from the user, e.g., physician, of a hand-held device, e.g.,Personal Digital Assistant (PDA), to record a voice file. The tag fileassociates the voice file to be recorded with a particular field in arecord of the template the user is creating. The tag file may betransmitted to the user of the hand-held device by the server. Theserver may receive the voice file along with the tag file upon the usercompleting the recording of the voice file. Upon transcription of thevoice file, the server may insert the transcription in the appropriatefield in the template created by the user using the tag file.

In one embodiment of the present invention, a method for creatingrecords using a hand-held device capable of recording a voice file maycomprise the step of receiving a request to select an encountertemplate. The method may further comprise transmitting one or morescreens of the selected encounter template and receiving a request togenerate a voice file to be inserted at a selected field in one of thetransmitted screens. A tag file may be generated in response to therequest to generate a voice file where the tag file associates the voicefile with the selected field in one of the transmitted screens intowhich the voice file is to be inserted. The method may further comprisetransmitting the tag file to a requesting device.

The foregoing has outlined rather broadly the features and technicaladvantages of one or more embodiments of the present invention in orderthat the detailed description of the invention that follows may bebetter understood. Additional features and advantages of the inventionwill be described hereinafter which form the subject of the claims ofthe invention.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the present invention can be obtained when thefollowing detailed description is considered in conjunction with thefollowing drawings, in which:

FIG. 1 illustrates a system configured in accordance with an embodimentof the present invention;

FIG. 2 illustrates an embodiment of the present invention of a server inthe system;

FIG. 3 illustrates an embodiment of the present invention of a hand-heldcomputer in the system;

FIG. 4 is a flowchart of a method for creating records using a browserhand-held computer in accordance with an embodiment of the presentinvention;

FIG. 5 is a data flow diagram illustrating the interactions between thedatabases and software in the server and the interactions between theserver and the hand-held computer for the method for creating recordsusing a browser hand-held computer in accordance with an embodiment ofthe present invention;

FIG. 6 is a data flow diagram illustrating the interactions between theserver and the hand-held computer when the user of the hand-heldcomputer selects to record a voice file in accordance with an embodimentof the present invention; and

FIG. 7 is a flowchart of a method for the user of the hand-held computerto record a voice file at a selected field in an encounter templatecreated by the user in accordance with an embodiment of the presentinvention.

DETAILED DESCRIPTION

The present invention comprises a method, computer program product andsystem for creating records using a hand-held device capable ofrecording a voice file. A server may receive a request to select anencounter template from the user of a hand-held computer, e.g., PersonalDigital Assistant (PDA). The server may transmit one or more screens ofthe selected encounter template to the hand-held computer. The servermay receive a request to generate a voice file to be inserted at aselected field in one of the transmitted screens. A tag file may begenerated in response to the request to generate a voice file where thetag file associates the voice file to be generated with the selectedfield in one of the transmitted screens into which the voice file is tobe inserted. The server may transmit the generated tag file to thehand-held computer.

Although the present invention is described in the context of aphysician's hand-held assistant embodiment that uses technology torecord field observations within the health care environment, it isnoted that the principles of the present invention may be applied toalternative embodiments such as optometry, paramedical/EMT, radiology,law enforcement, education, insurance adjusters, service/repairpersonnel, census takers, etc. It is further noted that that embodimentsapplying the principles of the present invention to such alternativeembodiments would fall within the scope of the present invention.

In the following description, numerous specific details are set forthsuch as specific protocols to provide a thorough understanding of thepresent invention. However, it will be apparent to those skilled in theart that the present invention may be practiced without such specificdetails. In other instances, well-known circuits have been shown inblock diagram form in order not to obscure the present invention inunnecessary detail. For the most part, details considering timingconsiderations and the like have been admitted inasmuch as such detailsare not necessary to obtain a complete understanding of the presentinvention and are within the skills of persons of ordinary skill in therelevant art

Referring to FIG. 1, FIG. 1 illustrates an embodiment of the presentinvention of a system 100. System 100 may comprise a client 120, e.g.,hand-held computer, that may be used by a user, e.g., physician, tocommunicate with a server 110 through a wireless medium. Server 110 isdescribed further below in conjunction with FIG. 2. Client 120 isdescribed further below in conjunction with FIG. 3. It is noted that thecommunication link between client 120 and server 110 may be any mediumtype, e.g., wired, and that FIG. 1 is illustrative. It is further notedthat FIG. 1 illustrates client 120 as being a hand-held computer.However, client 120 may be any type of device, e.g., wireless, cellphone, personal computer system, workstation, Internet appliance,Personal Digital Assistant (PDA), palmtop, smart phone, Pocket PC,configured with the capability of communicating with server 110. It isfurther noted that server 110 may refer to a software implementation, ageneral purpose data processing system or a stand alone hardware device.It is further noted that system 100 may be any type of system that hasat least one server and at least one client and that FIG. 1 is not to belimited in scope to any one particular embodiment

Server 110 may comprise a web page engine 111 for maintaining andproviding access to an Internet web page which is enabled to forward aHyper-Text Mark-up Language (HTML) file to a web browser 121 of client120. Web browser 121 may be configured for reading and interpreting webpages. While the illustrated client engine is a web browser 121, thoseskilled in the art will recognize that other client engines may be usedin accordance with the present invention and that the principles of thepresent invention may be implemented using other languages fordisplaying document elements with distinctive formats. These mayinclude, for example, XML (Extensible Markup Language) or SGML (StandardGeneralized Markup Language).

Turning now to FIG. 2, FIG. 2 illustrates an embodiment of the presentinvention of server 110. Server 110 may comprise a processor 210 coupledto various other components by system bus 212. An operating system 230may run on processor 210 and provide control as well as coordinate thefunction of the various components of FIG. 2. An application 240 inaccordance with the principles of the present invention may run inconjunction with operating system 230 and provide output calls tooperating system 230 where the output calls implement the variousfunctions or services to be performed by application 240. An application240 may include, for example, a program (including the web control,encounter template programmer and voice file engine as discussed furtherbelow) for creating records including inserting a transcribed voice filein the appropriate field in a record as described in association withFIGS. 4-6. It is noted that the steps of the method for creating recordsperformed by the program mentioned above may in an alternativeembodiment be implemented in hardware such as in an Application SpecificIntegrated Circuit (ASIC). Read only memory (ROM) 216 may be coupled tosystem bus 212 and include a Basic Input/Output System (“BIOS”) thatcontrols certain basic functions of server 110. Random access memory(RAM) 214, disk adapter 218 and transceiver 234 may also be coupled tosystem bus 212. It should be noted that software components includingoperating system 230 and application 240 may be loaded into RAM 214which may be the main memory for server 110. RAM 214 also may beconfigured to store databases, e.g., template database, diagnosisdatabase, report database, drug information database, master templateregistry, drug interaction/duplicate therapy/formulatory checker, FileTransfer Protocol (FOP) directory, as discussed in conjunction withFIGS. 5 and 6. Disk adapter 218 may be an integrated drive electronics(“IDE”) adapter that communicates with disk units 220. It is noted thatthe program of the present invention that creates records includinginserting a transcribed voice file in the appropriate field in a recordas described in FIG. 4 may reside in disk drive 220 or in application240. It is further noted that disk drive 220 may be configured to storedatabases, e.g., template database, diagnosis database, report database,drug information database, master template registry, druginteraction/duplicate therapy/formulatory checker, FTP directory, asdiscussed in conjunction with FIGS. 5 and 6. Transceiver 234 may beconfigured to receive/transmit data from/to client 120.

Implementations of the invention include implementations as a computersystem programmed to execute the method or methods described herein, andas a computer program product. According to the server implementations,sets of instructions for executing the method or methods may be residentin the random access memory 214 of one or more computer systemsconfigured generally as described above. Until required by server 120,the set of instructions may be stored as a computer program product inanother computer memory, for example, in disk drive 220 (which mayinclude a removable memory such as an optical disk or floppy disk foreventual use in disk drive 220). Furthermore, the computer programproduct may also be stored at another computer and transmitted whendesired to the user's workstation by a network or by an external networksuch as the Internet One skilled in the art would appreciate that thephysical storage of the sets of instructions physically changes themedium upon which it is stored so that the medium carries computerreadable information. The change may be electrical, magnetic, chemicalor some other physical change.

Turning now to FIG. 3, FIG. 3 illustrates an embodiment of the presentinvention of hand held computer 120, e.g., a PDA, palmtop, smart phone,Pocket PC, possessed by a user, e.g., physician. Hand held computer 120may comprise a processor 301 coupled to various other components by abus 302. An operating system 303 may run on processor 301 and providecontrol as well as coordinate the function of the various components ofFIG. 3. An application 304 in accordance with the principles of thepresent invention may run in conjunction with operating system 303 andprovides output calls to operating system 303 where the output callsimplement the various functions or services to be performed byapplication 304. Application 304 may include for example, web browser121 (FIG. 1), and a program for recording a voice file as described inconjunction with FIGS. 6 and 7. Read only memory (ROM) 305 may becoupled to bus 302 and include a Basic Input/Output System (“BIOS”) thatcontrols certain basic functions of hand held computer 120. Randomaccess memory (RAM) 306 and transceiver 307 may also be coupled to bus302. It should be noted that software components including operatingsystem 303 and application 304 may be loaded into RAM 306 which may bethe hand held computer's 120 main memory. RAM 214 may be configured tostore databases, e.g., documents directory, as discussed in conjunctionwith FIG. 6. Transceiver 307 may be configured to receive/transmit datafrom/to server 110.

Hand held computer 120 may further comprise a voice recorder 308 coupledto bus 302. Voice recorder 308 may be configured to record a voice fromthe user of hand-held computer 120 via microphone 309.

Input/Output devices may also be connected to bus 302 via a userinterface adapter 310 and display adapter 311. A microphone 309 and astylus 312 may be connected to bus 302 through user interface adapter310. A display 313 may be connected to bus 302 by display adapter 311.In this manner, a user may be capable of inputting to hand held computer120 through microphone 309, stylus 312 and receiving output from handheld computer 120 via display 313.

Implementations of the invention include implementations as a computersystem programmed to execute the method or methods described herein, andas a computer program product According to the computer systemimplementation, sets of instructions for executing the method or methodsare resident in the random access memory 306 of one or more computersystems configured generally as described above. Further, the computerprogram product may also be stored at another computer and transmittedwhen desired to the user's workstation by a network or by an externalnetwork such as the Internet. One skilled in the art would appreciatethat the physical storage of the sets of instructions physically changesthe medium upon which it is stored so that the medium carries computerreadable information. The change may be electrical, magnetic, chemical,biological or some other physical change.

Turning now to FIG. 4, FIG. 4 is a flowchart of one embodiment of thepresent invention of a method 400 for creating records using a browserbased hand-held assistant 120 (FIGS. 1 and 3) capable of recording avoice file to be later transcribed and inserted in the associatedrecord. It is noted that one of ordinary skill in the art will readilyrecognize that method 400 may include other and/or additional stepsthat, for clarity, are not depicted. It is further noted that method 400may be executed in a different order presented and that the orderpresented in the discussion of FIG. 4 is illustrative. It is furthernoted that certain steps in method 400 may be executed in asubstantially simultaneous manner.

Referring to FIG. 4, in conjunction with FIGS. 1-3, in step 401, server110 receives an HTTP request from the user of hand-held computer 120 tobegin a session. Upon receiving the HTTP request, server 110, in step402, transmits an HTML web page to hand-held computer 120 to logon theuser to access server 110 to create encounter templates as describedbelow. In step 403, a determination is made by server 110 as to whetherthe user successfully logged onto server 110. If the user did notsuccessfully log onto server 110, then, in step 404, server 110transmits to hand-held computer 120 a notification of an unsuccessfulattempt to logon onto server 110. Server 110 may also transmit a requestfor the user to try again to begin a session in step 404.

If the user did successfully log onto server 110, then, in step 405,server 110 transmits one or more HTML web pages to provide the choice ofenvironment, basic information on the patient and the encounter templateto create. The choice of environment may include the place of thepatients visit and the expected duration of the patient's stay. Examplesof a type of environment include an office visit, emergency room,outpatient and overnight stay at the hospital. Encounter may refer tothe type of injury or disease exhibited by the patient. For example, thepatient may have sustained a knee injury. The encounter template mayinclude one or more records in html (or other markup language) formatthat may be provided by server 110 for the user of hand-held computer120 to diagnose the encounter. A list of the templates may be maintainedin a master template registry as illustrated in FIG. 5.

Turning now to FIG. 5, FIG. 5 illustrates an embodiment of the presentinvention of a data flow diagram illustrating the interconnectionsbetween the databases and software in server 110. Server 110 maycomprise software, referred to herein as “web control” 501, configuredto control the interactions between the databases within server 110 andthe interactions between server 110 and hand-held computer 120. Server110 may further comprise software, referred to herein as “encountertemplate programmer” 515, configured to create the encounter templateset(s) that may be selected by the user of hand-held computer 120 byreferencing a sequence database 509 and based upon the user's input. Amethodology that may be used in conjunction with encounter templateprogrammer 515 will be described further below.

Server 110 may further comprise a template database 502 configured tostore data associated with various encounter templates. Templatedatabase 502 may comprise an element record data portion 503 configuredto store elements, e.g., titles, dropdowns, checkboxes, fill-ins,displayed to the user of hand-held computer 120 on each HTML web pagefor each encounter template that may be transmitted to hand-heldcomputer 120. Element record data portion 503 may further contain fieldsthat describe to web control 501 how to form the HTML web pages. Forexample, a “data type” field may inform web control 501 what kind ofelement it will create. A “c” in the data type field may inform webcontrol 501 to create a “checkbox” element. A “field tag” may become thename or text displayed with the checkbox. An “f” in the data type fieldmay inform web control 501 to create a “fill-in” element. A “q” in thedata type field may inform web control 501 to create a “question”element An illustrative element list is included herein as Appendix A.

Template database 502 may further comprise a transcription data portion504. Transcription data portion 504 may be macro data used to create thetextual information that may become part of a final report where thefinal report may include a complete encounter template created by theuser including any voice files recorded and transcribed. Each elementthat is created for the screen may be linked to a macro statement that,based on user input, will become part of the textual result. The finaldestination for the textual result may be controlled by the reportmapping data portion 505. These macro statements are inserted into areport database 506 from which the report is generated.

To evaluate the extent to which the physician has performed the exam isdetermined by a coding information portion 507 of template database 502.Elements of the exam may be related to values, which may be evaluated atthe end of the encounter to provide the physician an idea of thephysician's level of evaluation and management coding. Evaluation andmanagement coding is an indicator used to evaluate the healthcareprovider, e.g., physician. Typically, the evaluation and managementcoding includes information about the level of service provided by thehealthcare provider such as the content of the service provided, thenature of the presenting problem(s) and the time required to provide theservice.

Returning to FIG. 4, in conjunction with FIGS. 1-3 and 5, in step 406,server 110 receives from the user of hand-held computer 120 a selectedtemplate. In step 407, the selected template is located in mastertemplate registry 508 and a first page identifier is obtained. Step 407may be performed by web control 501. In step 408, this identifier isused to locate the name of the first page in a sequence database 509configured to store a sequence of HTML web pages to be provided to theuser for each particular encounter template. Step 408 may also beperformed by web control 501. An illustrative set of screen shots forthe knee template is included herein as Appendix B. In step 409, the oneor more matching records in template database 502 is located in sequencedatabase 509. In step 410, one or more HTML web pages of the one or morematching records are created. In step 411, these one or more HTML webpages are transmitted to hand-held computer 120. Steps 409-411 may alsobe performed by web control 501.

In step 412, server 110 receives results from the user of hand-heldcomputer 120 as the user completes filling-in the information on eachreceived HTML web page. In step 413, server 110 records the results fromthe user of hand-held computer 120 in a diagnosis database 510 as theuser completes filling-in the information on each received HTML webpage. Based on user input selections, conditions may be evaluated instep 414. For example, the condition of SSL may refer to a “ScreenSelection List” where the user, such as a physician, may selectparticular pages, e.g., allergic, neurological, of an encounter templateto be created. The pages or screens selected by the user may be selectedin sequence database 509. The condition of branching may include toproviding the user a range of choices in the diagnosis that results in adifferent sequence of HTML web pages being subsequently transmitted. Forexample, if the physician or nurse practitioner selected a crushed kneeversus a pulled knee, different HTML web pages would be created andtransmitted by web control 501 to the user thereby allowing the user tocreate a unique encounter template. In another example, the conditionmay be a voice file request as will be discussed further herein below.In another example, the condition may be a prescription request as willbe discussed herein further below. In another example, the condition maybe a template call. A template call may refer to a function invoked thatallows the user to branch to another template. For example, the user mayinvoke a function to suspend the current template being displayed and tostart another template to be generated.

In step 415, the next records or HTML web pages to be transmitted to theuser of hand-held computer 120 are selected by encounter templateprogrammer 515 by referencing sequence database 509 and based upon theuser's input, i.e., based upon the user's selection when provided a listof choices as discussed above. These elements are then transmitted tohand-held computer 120 via web control 501 in step 416. This processcontinues until the end of the sequence is reached. In step 417, server110 receives and records the results from the user of hand-held computer120 in a diagnosis database 510 as the user completes filling-in theinformation on each transmitted HTML web page.

If server 110 receives a request to review the current diagnosis, thendecision block 418 proceeds by the “yes” branch to step 419. In step419, readable description of the diagnosis so far inputted is created.In one embodiment, a readable description of the diagnosis may becreated by sending the information entered by the user which may bestored in the diagnosis database 510 to the report database 506. In step420, web control 501 transmits the readable description of the currentdiagnosis of the current encounter template to the user of hand-heldcomputer 120.

If, however, server 110 did not receive a request to review the currentdiagnosis, then, in step 421, a determination is made by server 110 asto whether a request to generate a voice file has been received. Ifserver 110 received a request to generate a voice file, then, in step422, server 110 generates a tag file associated with a voice file wherethe tag file may include a tracking number, a voice file sequencenumber, a doctor's HIPPA identifier, a topic, and an Internet Protocol(IP) address.

The tracking number may include a unique number assigned to the voicefile to be created that indicates the particular field the voice file isto be inserted on a particular HTML web page of the encounter template.For example, the user may be presented with a series of optionsincluding the option of inserting a voice file (textual transcription ofa voice recording). The user may select to insert a voice file toinclude a more complete diagnosis or observation than may be provided byselecting one of the options presented to the user.

The voice file sequence number may refer to the particular voice file,e.g., first, second, third voice file, to be inserted in the currentencounter template. The doctor's HIPPA identifier may include the uniqueHIPPA number each physician is assigned. The topic may refer to themedical discipline, e.g., internal medicine, gynecology. The EP addressmay be used for routing the text file to a service to perform proofingof the transcribed voice file.

In step 423, web control 501 places the generated tag file in an FTPdirectory as illustrated in FIG. 6. FIG. 6 illustrates a data flowdiagram illustrating the interactions between server 110 and hand-heldcomputer 120 when the user of hand-held computer 120 selects to record avoice file in accordance with an embodiment of the present invention.Referring to FIG. 6, server 110 may comprise an FTP directory 601 wherethe generated tag file 602 may temporarily be stored.

Returning to FIG. 4, in conjunction with FIGS. 5-6, in step 424, webcontrol 501 transmits tag file 602 to hand-held computer 120 to bereceived by control program 603 in hand-held computer 120. In step 425,tag file 602 is deleted. In one embodiment, tag file 602 is deleted byweb control 501 upon receiving from control program 603 of hand-heldcomputer 120 a notification of receiving tag file 602. In step 426, theprocess loops, breaking out of the loop if a voice file is received fromhand-held computer 120. The method of the user recording a voice file inhand-held computer 120 is provided below.

Referring to FIG. 7, FIG. 7 is a flowchart of a method 700 for the userof hand-held computer 120 to record a voice file to be inserted at aselected field on a screen being viewed by the user. Referring to FIG.7, in conjunction with FIG. 6, in step 701, control program 603 readsthe received tag file. In step 702, the received tag file is stored in adocuments directory 604 of hand-held computer 120. In step 703, voicerecorder 308 is activated by control program 603 to start recording theuser's dictation. In step 704, the user's dictation is recorded. It isnoted that in one embodiment, the user of hand-held computer 120 may beprovided with the option of recording the user's dictation at a latertime. The user may then at a later time select to record a dictationupon which control program 603 generates a request to server 110 torecord a voice file. In step 705, the recorded voice file may be namedaccording to the received tag file by control program 603. In oneembodiment, the voice file may be named by using the user's HIPPAidentifier which may be associated with a particular voice pattern. Inone embodiment, the HIPPA identifier may be prestored in hand-heldcomputer 120 (FIGS. 1 and 3) such as in ROM 305 (FIG. 3). In step 706,the recorded voice file 605, is stored in documents directory 604 bycontrol program 603. The voice file may be in a standard file format fordigital audio data such as a WAV file, a MPEG file, an AIFF file, etc.In step 707, control program 603 transmits the recorded voice file 605to server 110. In step 708, control program 603 deletes recording file605 such as to save memory space. In step 709, voice recorder 301 isdeactivated.

It is noted that one of ordinary skill in the art will readily recognizethat method 700 may include other and/or additional steps that, forclarity, are not depicted. It is further noted that method 700 may beexecuted in a different order presented, e.g., step 708 may be executedprior to step 709, and that the order presented in the discussion ofFIG. 7 is illustrative. It is further noted that certain steps in method700 may be executed in a substantially simultaneous manner.

Returning to FIG. 4, in conjunction with FIGS. 1-3 and 5-6, in step 427,web control 501 receives a voice file 605 attached with the tag filefrom hand-held computer 120. In step 428, the received voice file 605 isstored in a directory, which in an embodiment of the present inventionmay be an FTP directory 601. In step 429, voice file engine 511 isconfigured to recognize the received voice file 605. Method 400 mayproceed to one of two set of steps.

In one embodiment, method 400 may proceed by voice file engine 511transmitting the received voice file 605 to a third party transcriptionservice 512 in step 430. In step 431, voice file engine 511 receive thetranscribed voice file from the third party transcription service 512.In step 432, the transcribed voice file is verified for accuracy. Instep 433, voice file engine 511 integrates the transcribed voice file inthe diagnosis using the associated tag file. As discussed above, the tagfile may contain information used to insert the transcribed voice filein the appropriate field in one of the HTML pages of the encountertemplate.

In an alternative embodiment, method 400 may proceed by voice fileengine 511 transcribing the received voice file in step 434. In oneembodiment, voice file engine 511 may contain software configured totranscribe voice files into text An example of commercially availablevoice recognition software is ViaVoice®, a product of IBM Corporation,Armonk, N.Y. In step 435, the transcribed voice file is verified foraccuracy. In step 436, voice file engine 511 integrates the a bed voicefile in the diagnosis using the associated tag file. As discussed above,the tag file may contain information used to insert the transcribedvoice file in the appropriate field in one of the HTML pages of thecurrent encounter template.

Returning to step 421 of FIG. 4, in conjunction with FIG. 5, if server110 did not receive a request to generate a voice file, then, in step437, a determination is made as to whether server 110 received a requestto write a prescription. If so, then web control 501 of server 110, instep 438, receives the prescribed drug from the user of hand-heldcomputer 120. The prescribed drug may include the name of the drug, thedosage, information about generic substitutes, etc. In step 439, webcontrol 501 checks the prescribed drug against the patient profile usingdrug interaction/duplicate therapy/formulatory checker 514. Adetermination is made in step 440 by drug interaction/duplicatetherapy/formulatory checker 514 as to whether there are any problems,e.g., patient allergic to prescribed drug, drug interaction, withprescribing this drug for the patient. If there is a problem withprescribing this drug for the patient, then, in step 441, web control501 transmits a notification to hand-held computer 120 indicating thatthere is a problem with prescribing this drug for the patient. If thereis no problem with prescribing this drug for the patient, then, in step442, the prescription is printed or transmitted to the appropriatehealthcare provider, e.g., pharmacy.

If server 110 did not receive a request to write a prescription, then,in step 443, a determination is made as to whether server 110 receivedan image request, e.g., x-rays, CT scan, Magnetic Resonance Imaging(MRI), Magnetic Resonance Angiograhy (MRA), ultrasound, nuclearmedicine, to be performed on a particular patient, e.g., x-ray rightknee on patient If server 110 received an image request, web control 501transmits a notification in step 444 to the appropriate healthcareprovider such as a radiologist or other imaging technicians.

If server 110 did not receive an image request, then, in step 445, adetermination is made as to whether server 110 received a lab request,e.g., blood test for patient xyz, to be performed on the patient Ifserver 110 received a lab request, web control 501 transmits anotification in step 446 to the appropriate healthcare provider, e.g.,lab technicians, to prepare to perform laboratory work on the patient.

If server 110 did not receive a lab request, then, in step 447, adetermination is made as to whether server 110 received a request forinformation about a particular drug. If server 110 received a requestfor drug information, then, in step 448, web control 501 searches therequested drug information in drug information database 513. In step449, web control 501 transmits the requested drug information tohand-held computer 120.

If server 110 did not receive a request for drug information, then, instep 450, a determination is made by server 110 as to whether the useris finished creating the current encounter template. If the user isfinished creating the current encounter template, then method 400 isterminated in step 451. If the user is not finished creating the currentencounter template, then in step 415, the next records or HTML web pagesto be transmitted to the user of hand-held computer 120 are selected byreferencing sequence database 509 and based upon the user's input, i.e.,based upon the user's selection when provided a list of choices asdiscussed above.

Although the method, computer program product and system are describedin connection with several embodiments, it is not intended to be limitedto the specific forms set forth herein, but on the contrary, it isintended to cover such alternatives, modifications and equivalents, ascan be reasonably included within the spirit and scope of the inventionas defined by the appended claims. It is noted that the headings areused only for organizational purposes and not meant to limit the scopeof the description or claims.

Element List for the Encounter Template Programmer

Element Types Data Type Code Branch Conditions Branch BR Branch QuestionBQ Branch Custom BC Branch To Template BT Checkboxes Checkbox C CheckboxPlus C+ Checkbox with Branch CB Checkbox Plus with Branch C+B Checkboxwith Explanation CE Display Types Display Local Data DLD Display LocalData/Edit DLE Display Template Data DTD Display Current Date DCD DisplayCurrent Time DCT Dropdown Lists Dropdown D Dropdown/Fill-In DF Dropdownwith Branch DB Dropdown/Fill-In with Branch DFB Link Field L Range FieldR Fill-in Fields Fill-In F Ordered Fill-In OF Look and Feel BackgroundColor BG Base Font Color BF Blank Record BL Title Record T QuestionsQuestion Q Question Custom QC Question with Explanation QE Radio ButtonsRadio Button RO Radio Button List RL Radio Button with Branch ROB RadioButton List with Branch RLB Radio Button Horizontal RH Radio ButtonHorizontal with Branch RHB Screen Selection Screen Selection List SSLScreen Selection Radio SSR Screen Selection/Branch SSB Template ReturnTR Wizards Voice File Checkbox Medication/Rx Righter Rx Righter Y/N/NAHorizontal Radio

1. A method for creating records using a hand held device capable ofrecording a voice file comprising the steps of: receiving a request toselect an encounter template; transmitting one or more screens of saidselected encounter template; receiving a request to generate a voicefile to be inserted at a selected field in one of said one or morescreens; generating a tag file in response to said request to generatesaid voice file, wherein said tag file associates said voice file withsaid selected field in one of said one or more screens; and transmittingsaid tag file to a requesting device.
 2. The method as recited in claim1, wherein said tag file comprises at least one of the following: atracking number, a voice file sequence number, a topic, and an InternetProtocol address.
 3. The method as recited in claim 1 further comprisingthe steps of: receiving said voice file; and transmitting said receivedvoice file to be transcribed.
 4. The method as recited in claim 3further comprising the steps of: receiving said transcribed voice file;and integrating said transcribed voice file in said encounter templateusing said tag file.
 5. The method as recited in claim 4 furthercomprising the step of: verifying accuracy of said transcribed voicefile prior to integrating said transcribed voice file in said selectedencounter template.
 6. The method as recited in claim 1 furthercomprising the steps of: receiving said voice file; and transcribingsaid received voice file.
 7. The method as recited in claim 6 furthercomprising the step of: integrating said transcribed voice file in saidselected encounter template using said tag file.
 8. The method asrecited in claim 1 further comprising the step of: transmitting a set ofscreens, wherein a first of said set of screens being operable forselecting an environment, wherein a second of said set of screens beingoperable for selecting said encounter template.
 9. The method as recitedin claim 8 further comprising the steps of: receiving results as a usercompletes each of said one or more transmitted screens of said selectedencounter template; and recording results as said user completes each ofsaid one or more transmitted screens of said selected encountertemplate.
 10. The method as recited in claim 9 further comprising thestep of: selecting a next one or more screens to be transmitted uponsaid user completing said one or more transmitted screens of saidselected encounter template.
 11. The method as recited in claim 10,wherein said selection of said next one or more screens to betransmitted is based on said results received.
 12. The method as recitedin claim 11, wherein said selection of said next one or more screens tobe transmitted is effected by referencing a database containing asequence of screens to be transmitted for said selected encountertemplate.
 13. The method as recited in claim 1 further comprising thesteps of: receiving a request to write a prescription; receiving a nameof a prescribed drug; and checking said name of said prescribed drugagainst a patient profile.
 14. The method as recited in claim 13 furthercomprising the step of: transmitting a notification indicating a problemwith prescribing said prescribed drug if there exists a problem withprescribing said prescribed drug.
 15. The method as recited in claim 13further comprising the step of: printing out said prescription.
 16. Themethod as recited in claim 13 further comprising the step of:transmitting said prescription for filling.
 17. The method as recited inclaim 1 further comprising the step of: receiving a request for druginformation.
 18. The method as recited in claim 17 further comprisingthe steps of: searching said requested drug information in a database;and transmitting said requested drug information.
 19. A computer programproduce embodied in a machine readable medium for creating records usinga hand held device capable of recording a voice file comprising theprogramming steps of: receiving a request to select an encountertemplate; transmitting one or more screens of said selected encountertemplate; receiving a request to generate a voice file to be inserted ata selected field in one of said one or more screens; generating a tagfile in response to said request to generate said voice file, whereinsaid tag file associates said voice file with said selected field in oneof said one or more screens; and transmitting said tag file to arequesting device.
 20. The computer program product as recited in claim19, wherein said tag file comprises at least one of the following: atracking number, a voice file sequence number, a topic, and an InternetProtocol address.
 21. The computer program product as recited in claim19 further comprising the programming steps of: receiving said voicefile; and transmitting said received voice file to be transcribed 22.The computer program product as recited in claim 21 further comprisingthe programming steps of: receiving said transcribed voice file; andintegrating said transcribed voice file in said encounter template usingsaid tag file.
 23. The computer program product as recited in claim 22further comprising the programming step of: verifying accuracy of saidtranscribed voice file prior to integrating said transcribed voice filein said selected encounter template.
 24. The computer program product asrecited in claim 19 further comprising the programming steps of:receiving said voice file; and transcribing said received voice file.25. The computer program product as recited in claim 24 furthercomprising the programming step of integrating said transcribed voicefile in said selected encounter template using said tag file.
 26. Thecomputer program product as recited in claim 19 further comprising theprogramming step of: transmitting a set of screens, wherein a first ofsaid set of screens being operable for selecting an environment, whereina second of said set of screens being operable for selecting saidencounter template.
 27. The computer program product as recited in claim26 further comprising the programming steps of: receiving results as auser completes each of said one or more transmitted screens of saidselected encounter template; and recording results as said usercompletes each of said one or more transmitted screens of said selectedencounter template.
 28. The computer program product as recited in claim27 further comprising the programming step of: selecting a next one ormore screens to be transmitted upon said user completing said one ormore transmitted screens of said selected encounter template.
 29. Thecomputer program product as recited in claim 28, wherein said selectionof said next one or more screens to be transmitted is based on saidresults received.
 30. The computer program product as recited in claim28, wherein said selection of said next one or more screens to betransmitted is effected by referencing a database containing a sequenceof screens to be transmitted for said selected encounter template. 31.The computer program product as recited in claim 19 further comprisingthe programming steps of: receiving a request to write a prescription;receiving a name of a prescribed drug; and checking said name of saidprescribed drug against a patient profile.
 32. The computer programproduct as recited in claim 31 further comprising the programming stepof: transmitting a notification indicating a problem with prescribingsaid prescribed drug if there exists a problem with prescribing saidprescribed drug.
 33. The computer program product as recited in claim 31further comprising the programming step of: printing out saidprescription.
 34. The computer program product as recited in claim 31further comprising the programming step of: transmitting saidprescription for filling.
 35. The computer program product as recited inclaim 19 further comprising the step of: receiving a request for druginformation.
 36. The computer program product as recited in claim 35further comprising the programming steps of: searching said requesteddrug information in a database; and transmitting said requested druginformation.
 37. A system, comprising: a memory unit operable forstoring a computer program operable for creating records; and aprocessor coupled to said memory unit, wherein said processor,responsive to said computer program, comprises: circuitry operable forreceiving a request to select an encounter template; circuitry operablefor transmitting one or more screens of said selected encountertemplate; circuitry operable for receiving a request to generate a voicefile to be inserted at a selected field in one of said one or morescreens; circuitry operable for generating a tag file in response tosaid request to generate said voice file, wherein said tag fileassociates said voice file with said selected field in one of said oneor more screens; and circuitry operable for transmitting said tag fileto a requesting device.
 38. The system as recited in claim 37, whereinsaid tag file comprises at least one of the following: a trackingnumber, a voice file sequence number, a topic, and an Internet Protocoladdress.
 39. The system as recited in claim 37, wherein said processorfurther comprises: circuitry operable for receiving said voice file; andcircuitry operable for transmitting said received voice file to betranscribed.
 40. The system as recited in claim 39, wherein saidprocessor further comprises: circuitry operable for receiving saidtranscribed voice file; and circuitry operable for integrating saidtranscribed voice file in said encounter template using said tag file.41. The system as recited in claim 40, wherein said processor furthercomprises: circuitry operable for verifying accuracy of said transcribedvoice file prior to integrating said transcribed voice file in saidselected encounter template.
 42. The system as recited in claim 37,wherein said processor further comprises: circuitry operable forreceiving said voice file; and circuitry operable for transcribing saidreceived voice file.
 43. The system as recited in claim 42, wherein saidprocessor further comprises: circuitry operable for integrating saidtrans%nWed voice file in said selected encounter template using said tagfile.
 44. The system as recited in claim 37, wherein said processorfurther comprises: circuitry operable for transmitting a set of screens,wherein a first of said set of screens being operable for selecting anenvironment, wherein a second of said set of screens being operable forselecting said encounter template.
 45. The system as recited in claim44, wherein said processor further comprises: circuitry operable forreceiving results as a user completes each of said one or moretransmitted screens of said selected encounter template; and circuitryoperable for recording results as said user completes each of said oneor more transmitted screens of said selected encounter template.
 46. Thesystem as recited in claim 45, wherein said processor further comprises:circuitry operable for selecting a next one or more screens to betransmitted upon said user completing said one or more transmittedscreens of said selected encounter template.
 47. The system as recitedin claim 46, wherein said selection of said next one or more screens tobe transmitted is based on said results received.
 48. The system asrecited in claim 46, wherein said selection of said next one or morescreens to be transmitted is effected by referencing a databasecontaining a sequence of screens to be transmitted for said selectedencounter template.
 49. The system as recited in claim 37, wherein saidprocessor further comprises: circuitry operable for receiving a requestto write a prescription; circuitry operable for receiving a name of aprescribed drug; and circuitry operable for checking said name of saidprescribed drug against a patient profile.
 50. The system as recited inclaim 49, wherein said processor further comprises: circuitry operablefor transmitting a notification indicating a problem with prescribingsaid prescribed drug if there exists a problem with prescribing saidprescribed drug.
 51. The system as recited in claim 49, wherein saidprocessor further comprises: circuitry operable for printing out saidprescription.
 52. The system as recited in claim 49, wherein saidprocessor further comprises: circuitry operable for transmitting saidprescription for filling.
 53. The system as recited in claim 37, whereinsaid processor further comprises: circuitry operable for receiving arequest for drug information.
 54. The system as recited in claim 53,wherein said processor further comprises: circuitry operable searchingsaid requested drug information in a database; and circuitry operabletransmitting said requested drug information.